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Pulmonology Flashcards

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1
Q

asthma is…

A

=REVERSIBLE

  • increasing incidence
  • wheezing, SOB, cough
  • worse at night
  • eczema, atopic dermatitis
  • inc length of expiration phase

-pulsus paradoxus

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2
Q

asthma causes/exacerbations

A

-allergens, infection, cold air, exercise, ASA, NSAIDs, beta blockers, tobacco smoke, GERD

  • ASA –> dec prostaglandins
  • beta blockers –> bronchoconstriction
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3
Q

asthma dx

A
  • severe px: ABG (arterial blood gas) or PEF (peak expiratory flow)
  • severe hypoxia, resp acidosis
  • CXR: to rule out PNA, CHF, pneumothorax
  • PFTs = most accurate test (out-patient setting)
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4
Q

asthma PFTs

A
  • dev FEV1
  • dec FVC
  • dec FEV1/FVC
  • indicates obstruction
  • inc TLC (hyperinflation)
  • inc residual volume (air trapping)
  • REVERSIBLE: FEV1 inc >12% with albuterol
  • methacholine –> dec FEV1 20% (bronchial hyper-responsiveness)
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5
Q

acetylcholine & histamine provoke:

A

bronchoconstriction and inc bronchial secretions

-methacholine = acetylcholine

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6
Q

asthma tx (mild intermittent)

A

= <2days/week

-short acting beta agonist (albuterol, levalbuterol)

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7
Q

asthma tx (mild persistent)

A

= >2days/week or >2nights/week

  • short acting beta agonist +
  • low dose inhaled corticosteroid (beclomethasone, budesonide, flunisolide, fluticasone, mometasone, tricinolone)
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8
Q

asthma tx (moderate persistent)

A

= daily or >1night/week

  • short acting beta agonist + low dose inhaled corticosteroid +
  • long acting beta agonist (LABA = salmerterol, formoterol)
  • inc dose of ICS
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9
Q

asthma tx (severe persistent)

A
  • max dose of ICS

- LABA and SABA

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10
Q

SE of inhaled corticosteroids (ICS)

A

dysphonia & oral candidiasis

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11
Q

cromolyn

A

=inhibitor of mast cell mediator release

-tx exercise-induced asthma

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12
Q

theophylline

A

=phosphodiesterase inhibitor –> inc cAMP levels

-cardio and neurotoxicity

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13
Q

leukotriene modifiers

A

= montelukast, zafirlukast, zileuton

  • atopic patients
  • zafrilukat = hepatotoxic, associated with Churg-Strauss syndrome
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14
Q

asthma acute flare

A

-O2
-albuterol (nebulized)
+/-ipratropium
-cortocosteroids (immediate administration bc it takes time for onset of effects)

  • no epi –last resort
  • Mg: helps when refractory to albuterol
  • not theophylline, leukotrienes, cromolyn, salmeterol
  • intubation: if they develop resp acidosis
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15
Q

best indication of severity of asthma flare

A

respiratory rate

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16
Q

alpha 1 antitrypsin deficiency

A
  • unable to break down molecules that destroy elastin
  • looks like emphysema
  • young, non smoker
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17
Q

COPD

A
  • barrel chest from inc air trapping
  • SOB
  • intermittent exacerbations
  • muscle wasting & cachexia due to inflammatory process
  • dec FEV1, FVC, FEV1:FVC (<70%)
  • inc TLC from air trapping
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18
Q

COPD dx

A
  • CXR = best initial test
  • rule out PNA
  • inc AP diameter from inc TLC
  • air trapping and flattened diaphragms
  • PFT = most accurate test
  • incomplete improvement with albuterol and no worsening with methacholine (as opposed to asthma)
  • ABG: inc CO2 & hypoxia
  • EKG: right sided hypertrophy; a fib, MAT
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19
Q

emphysema –> dec DLCO

A

dec O2 delivered due to destruction of alveolar septae

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20
Q

COPD tx (mortality vs symptom improvement)

A

improved mortality:

  • smoking cessation
  • O2 therapy

improved symptoms:

  • SABA (albuterol)
  • anticholinergic (tio- and ipratropium)*** useful in COPD
  • inhaled steroids
  • LABA (salmeterol)
  • pulmonary rehabilitation

never: cromolyn or leukotrienes

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21
Q

COPD exacerbation tx

A

-bronchodilators + corticosteroids

same for asthma exacerbation, but less proven benefit

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22
Q

COPD O2 supplementation

A
  • avoid high flow O2 supplementation
  • will remove their hypoxic drive to breath
  • just raise pO2 > 90%
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23
Q

COPD antibiotic tx

A
  • for mod-severe exacerbation
  • inc dyspnea, sputum, or sputum purulence

-protect against strep pneumonia, h influenza, moraxella

  • macrolides (azithromycin, clarithromycin)
  • cephalosporins (cefuroxime, cefixime)
  • amoxicillin/clavulanic acid
  • quinolones (levo, moxifloxacin)

-doxycycline,TMP-SMX

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24
Q

bronchiectasis =

A

destruction, remodeling, dilation of large bronchi

permanent

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25
bronchiectasis causes
``` CF infections (TB, MAI) PNA (Staph, aspiration) panhypogammagloobulinemeia ABPA tumors RA Kartagener syndrome (immotile cilia) ``` cause repeat persistent lung infections
26
bronchiectasis dx
best initial = CXR most accurate = high resolution chest CT
27
bronchiectasis tx
- postural drainage (dislodge plugged bronchi) - treat infections (same as for COPD exacerbations) - surgical resection (focal lesions)
28
allergic bronchopulmonary aspergillosis (ABPA)
hypersensitivity/allergy to fungal antigens that normally colonize bronchial tree - often in asthma or atopic pts - brown flecked sputum - cough, wheezing, hemoptysis, bronchiectasis
29
ABPA dx
- peripheral eosinophilia - elevated IgE - pulmonary infiltrates on CXR or CT
30
ABPA tx
- oral steroids (prednisone) - no inhaled steroids bc not a high enough dose - itraconazole or voriconazole for recurrent episodes
31
CF
- autosomal recessive mutation for Cl transport (CFTR) | - damage Cl & water transport across apical surface of epithelial cells in exocrine glands
32
CF px
-thick mucus from exocrine gland - nasal polyps, sinusitis - bronchiectasis, bronchitis, PNA, pulmonary HTN, cor pulmonale, ABPA - R ventricular hypertrophy - GERD - malabsoprtion of vit ADEK - hepatic steatosis, portal HTN - biliary cirrhosis, cholelithiasis - pancreatitis-->DB, insulin deficiency - meconium ileus - infertility (azoospermia), amenorrhea (abnormal menstruation or inc cervical mucus blocks sperm) - digital clubbing, arthritis
33
CF infections
mucus plugging allows bacteria to grow (<-- WBCs dump DNA into airways) - H flu - Pseudomonas aeruginosa - Staph aureus - Burkholderia cepacia
34
CF dx
- inc sweat Cl test - pilocarpine --> in ACh --> inc sweat production - Cl>60 = CF
35
CF tx
- antibiotics to eliminate colonization - sputum culture - inhaled aminoglycosides (tobramycin) - inhaled rhDNase = breaks down DNA in resp mucus - inhaled bronchodilators (albuterol) - lung transplantation
36
CF hemoptysis tx
- rigid bronchoscopy - bronchial embolization via IR -"bad lung-side down" to prevent bleeding into "healthy" lung
37
community acquire pneumonia (CAP) organisms
-Strep pneumo = most common - H flu - COPD - Staph - after influenza - Klebsiella - alcoholism, DB - anaerobes - poor dentition - Mycoplasma - young healthy (college; "walking PNA") - Chlamydia - hoarse voice - Legionella - contaminated water source - Chlamydia psittaci - birds - Coxiella burnetii - animals, vets, farmers
38
dullness to percussion due to?
effusion
39
egophany due to?
consolidation
40
Klebsiella px
hemoptysis | "currant jelly"
41
Anaerobes px
foul smelling sputum
42
Mycoplasma pneumonia px
dry cough | bullous myringitis
43
Legionella px
GI symptoms: abdominal pain, diarrhea | CNS symptoms: headache, confusion
44
Pneumocystis patients?
AIDS: CD4<200
45
dry cough causes?
-involve interstitial space, not alveoli --> less sputum ``` mycoplasma virus coxiella pneumocystis chlamydia ```
46
CAP dx
CXR = best initial test sputum gram stain
47
atypical PNA
not visible on gram stain mycoplasma, chlamydophila, legionella, coxiella, viruses 30-50% of CAP CXR: interstitial infiltrates; spares air spaces; hazy lung fields
48
thoracentesis used for what?
-tx for pleural effusions
49
empyema =
infectious pleural effusion tx: thoracentesis & chest tube for drainage LDH>60% protein>50% pH<7.2
50
Strep pnemo dx
tested via urine antigen
51
Mycoplasma pneumonia dx
PCR cold agglutins serology special culture media
52
Chlamydia dx
rising serologic titers
53
Legionella dx
``` urine antigen (similar to Strep pneumo) culture on charcoal-yeast extract ```
54
Pneumocystis jiroveci (PCP) dx
bronchoalveolar lavage (BAL)
55
CAP tx outpatient
previously healthy: macrolide (azithromycin or clarithromycin) OR doxycycline comorbidities: respiratory floroquinolones (levofloxacin or moxifloxicin)
56
CAP tx inpatient
respiratory floroquinolone (levofloxacin or moxifloxacin) OR ceftriaxone and azithromycin
57
CAP vs HAP
CAP: PNA before hospital visit or within 48 hours of hospitalization HAP: >48 hours of hospitalization
58
reasons to hospitalize
- hypotension 30 - pO2 30 - Na 125 - pulse >125 - confusion - temp >104F - >65YO or comorbidities hypoxia + hypotension CURB 65 = confusion, uremia, resp distress, BP low, age 65
59
pneumococcal vaccine administration to?
- everyone >65YO - chronic heart disease, liver, kidney, or lung disease - aplenic pts - malignancy, DB, AIDS, HIV
60
healthcare PNA
>48 hours after admission - gram(-) --> E coli or Pseudomonas - no macrolide tx
61
HCAP tx
- gram (-) coverage - antipseudomonal cephalosporins (cefepime or ceftazidime) - antipseudomonal penicillin (pipercilling/tazobactam = zosyn) - carbapenems (imipenem, meropenem, doripenem)
62
ventilator associated PNA
- interferes with normal mucociliary clearance | - damages normal ability to clear colonization
63
VAP dx & tx
- protected brush specimen (dangerous) - bronchoalveolar lavage - tracheal aspirate - 1 antipseudomonal beta-lactam (ceftazidime, cefepime, pipercillin/tazobactam, imipenem, meropenem, doripenem) - 1 aminoglycoside (gentamicin or tobramycin) - 1 MRSA agent (vancomycin or linezolid)
64
subcutaneous emphysema
=air abnormally leaking into soft tissue of chest wall -causes: chest tube
65
imipenem causes
seizures (lowers threshold) -excreted from kidney; thus AKI can cause toxicity
66
lung abscess
-cause by aspiration PNA - stroke + loss of gag reflex, seizure, intoxication, endotracheal intubation - right upper lobe when lying flat
67
lung abscess px & dx
- foul smelling sputum - caused by anaerobes - CXR = best initial --> cavity with air fluid level - chest CT = most accurate - lung biopsy to find microbiology etiology (NEVER sputum culture)
68
lung abscess tx
clindamycin
69
PCP PNA px
- AIDS pts - CD4 <200 -severe dyspnea on exertion, dry cough, fever
70
PCP dx
- CXR -bilateral interstitial infiltrates - ABG -hypoxia -elevated LDH
71
PCP tx
-TMP-SMX =tx & prophylaxis -steroids to dec mortality - mild: atovoquone - TMP-SMX toxicity: clindamycin, primaquine, pentamidine
72
adverse effects of TMP-SMX
rash | bone marrow suppression
73
azithromycin in HIV protects against?
atypicals, MAI (mycoplasma) when CD4<50
74
TB risk factors
- recent immigration (past 5 years) - prisoners - HIV - healthcare workers - close contact to TB - steroid use - hematologic malignancy - alcoholics - DB
75
TB px
fever, cough, sputum, weight loss, hemoptysis, night sweats >3 weeks
76
TB dx
- CXR = best initial - AFB = most specific - 3 negative AFB = negative TB test - bronchoscopy with BAL or pleural biopsy if high suspicion but negative tests -PPD = screening
77
typical TB CXR
- upper lobe cavity infiltrate | - cavity = reactivation of latent infection
78
TB tx
Rifampin Isoniazid Pyrazinamide Ethambutol -ehtambutol give prior to sensitivity testing; removed if TB sensitive to other drugs -stop ethambutol and pyrazinamide after 2 months -continue rifampin and isoniazid for next 4 months =6 months of total therapy
79
9 months of TB tx
osteomyelitis, miliary TB, meningitis, pregnancy (pyrazinamide not used)
80
rifampin SE
- hepatotoxicity | - red body secretions
81
isoniazid SE
- hepatotoxicity | - peripheral neuropathy (tx with pyridoxine = B6)
82
pyrazinamide SE
- hepatotoxicity - hyperuricemia (only tx if they have gout) -NOT FOR PREGNANT PTS
83
ethambutol SE
- hepatotoxicity - optic neuritis - color change -dec dose in renal failure
84
steroids in TB
- dec constrictive pericarditis | - dec neurologic complications
85
PPD testing
- screening only for risk groups - NOT for symptomatic pts - NOT diagnostic
86
PPD
- induration = + - erythema is not + - >5mm : HIV, glucocorticoid, transplant receptors - >10mm : recent immigrant, prisoner, HC worker, hematologic malignancy - >15mm : no risk factors - CXR if positive PPD
87
positive PPD, next?
9 months of isoniazid
88
when to biopsy a pulmonary nodule? | inc risk for malignancy
- >40YO - change in size in serial films - smoker - spiculated borders - >2cm - atelectasis (post-obstructive process) - adenopathy - sparse, eccentric calcification
89
infectious vs malignant nodule?
- both have enlarging lung lesions | - infectious doubles in size in <30 days (faster than cancer)
90
malignant pulmonary nodule tx?
resection -many false negatives with PET, cytology, needle biopsy
91
PET scan
- malignancy has increased uptake of tagged glucose | - high sensitivity
92
VATS (video-assisited thoracic surgery)
- frozen section in operating room | - immediate conversion to open thoracoscopy and lobectomy if malignancy found
93
benign pulmonary nodules by location: - immigrant - SW, USA - Ohio river valley, USA
- TB - coccidiomycosis - histoplasmosis
94
pneumoconioses types: - coal - sandblasting/ rock/ mining/ tunneling - shipyard workers/ pipe fitting/ insulators - cotton - electronic manufacturers - moldy sugar cane
- coal worker's - silicosis - asbestosis - byssinosis - berylliosis ***granulomas - bagassosis
95
is fibrosis reversible?
NO
96
interstitial lung disease dx
- CXR = best initial - chest CT = more accurate ("honeycombing") - lung biopsy = most accurate
97
interstitial lung disease PFTs
- decreased FEV1, FVC, TLC, RV - FEV1/FVC ratio is normal - decreased DLCO (septal thickening)
98
berylliosis tx
responds best to steroids | granulomas represent inflammation
99
sarcoidosis px
- noncaseating granulomas (lung) - young African American woman - erythema nodosum - lymphadenopathy (hilar, bilateral) - heart block - restrictive cardiomyopathy
100
sarcoidosis dx
- CXR = best initial (hilar lymphadenopathy) - lymph node biopsy = most accurate (non-caseating granulomas) - elevated ACE - hypercalciuria - hyperCa (granulomas make vitamin D) - PFT --> restrictive lung disease
101
sarcoidosis tx
-prednisone (few pts fail to respond) -asymptomatic pts do not need to be treated
102
Virchow's triad = predisposing factors to thromboembolism
1. ) stasis of blood flow (immobility, CHF, recent surgery) 2. ) hypercoagulability (Factor V Leiden, malignancy) 3. ) endothelial injury (trauma, surgery, recent fracture)
103
PE px
tachypnea + tachycardia + cough + hemoptysis - leg pain from DVT - pleuritic CP - fever - hypotension
104
PE dx
- CXR (often normal) - EKG (sinus tachy; S1Q3T3) - ABG (hypoxia + respiratory alkalosis --from tachypnea) - confirm with spiral CT angiogram - D-dimer --> very sensitive, poor specificity (negative excludes, positive means nothing) - angiography = most accurate (rarely used)
105
when do you use a D-dimer test?
when pretest probability of PE is low
106
(+) lower extremity doppler study… next?
- no further dx | - treat for PE (unfractionated heparin)
107
PE tx
- IV heparin = best initial - start oral warfarin simultaneously - IVC filter if anticoagulation contraindicated, recurrent emboli on heparin, RV dysfunction - thrombolytics --pts hemodynamically unstable - direct-acting thrombin inhibitors --hx of HITT -NEVER USE ASA for DVT tx
108
causes of pulmonary HTN
-left sided heart failure = MCC -L-->R shunt -hypoxic vasoconstriction from COPD -PE (chronic hypoxemia) -idiopathic
109
pulmonary HTN px
- exertional syncope - exertional CP - dyspnea, fatigue - right heart failure, edema, JVD
110
pulmonary HTN dx
- CXR = best initial (dilation of proximal arteries) - Swan-Ganz Katheter = most accurate (measures pulmonary capillary wedge pressure = LA pressure = LVED pressure) - EKG (RAD, RV hypertrophy) - echo (R heart hypertrophy) - V/Q scanning - CBC (polycythemia)
111
pulmonary HTN tx
- prostacyclin analogues --> pulmonary artery vasodilation - endothelin antagonists (bosentan) - phosphodiesterase inhibitors (sildenafil) - oxygen slows progression - not CCBs -cure: lung transplantation
112
symptoms of OSA
- daytime somnolence - snoring - headache (early morning hypercarbia) - impaired memory & judgement - depression - HTN - erectile dysfunction
113
OSA dx
polysomnography = sleep study = most accurate -shows multiple episodes of apnea
114
OSA tx
-treat risk factors (men, overweight) - weight loss - CPAP --positive airway pressure throughout the night -avoid sedative
115
ARDS px
=overwhelming lung injury or systemic disease -endothelial injury in aleveoli --> leaky --> alveoli fill with fluid - severe hypoxia - poor lung compliance - noncardiogenic pulmonary edema
116
ARDS dx
- CXR = dense bilateral infiltrates --> white out - air bronchograms = hyperlucent air within congestion - PaO2/FiO2 ratio <18 mmHg)
117
ARDS tx
- mechanical ventillation - low tidal volume (6mL/kg) - PEEP -steroids can reduce pulmonary fibrosis

Internal Medicine (9 decks)

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